HSS4331 – International Health Theory

1. HSS4331 – International Health Theory HIV/AIDS Nov 9, 2009

2. Today…. • HIV/AIDS • Africa

3. Today…. • I will present to you what most researchers think about the HIV/AIDS pandemic • Next week, we will have a guest lecture by HIV/Africa specialist Dr Ed Mills who will present a slightly different –and maybe controversial-- viewpoint

4. HIV/AIDS • The basics • “Acquired Immune Deficiency Syndrome” • Caused by “Human Immunodeficiency Virus” • Evidence of infection before 1970 • Current pandemic started in late 1970s, early 1980 • AIDS defined in 1982 • First identified in gay community in USA • Originally called “GRID” – gay-related immune deficiency

5. Transmitted via… • Sex • Needle sharing • Blood transfusions • Mother-to-infant • Any other activity that allows meaningful contact of body fluids

6. Timeline… • 1983: Pasteur Institute in France discovers HIV – “Human Immunodeficiency Virus” • If not treated, those with HIV will develop AIDS in 8-10 years • 1995: protease inhibitors dramatically increase survival of HIV patients with access

7. Alternative Theory • A minority of scientists question the link between HIV and AIDS • http://www.orgonelab.org/hiv_aids.htm

8. Treatment • “Cocktail” • “highly active anti-retroviral therapy” – HAART • ARV = anti retroviral therapy • Serious side effects • Regimens can be complicated • Can be very expensive

9. Affordability of ARV drugs -gone down from $10,000/year to $200/year Last year, the European Commission ruled that EU countries are free to make available generic versions of patented drugs for export to poor countries which lack their own manufacturing facilities. Trade Related Intellectual Property Rights (TRIPS)

10. Death • People don’t “die from AIDS” • AIDS allows “opportunistic infections” • Leading cause of death of AIDS patients is bacterial infection • Tuberculosis • Fungal infections • Pneumonia

11. Co-infection with TB • 1/3 of the world is currently infected with TB, though most are not “active” cases • 5-10% will develop active TB disease • Only 25% have access to treatment • TB accounts for 13% of all AIDS deaths • HIV is the strongest known risk factor for a TB carrier to progress to full TB disease

12. Co-infection with STDs • In the presence of an STD, chance of acquiring HIV increases 5X • Puts sex workers at even greater risk

13. Diagnosis • Bloodtest • Looking for HIV antiobodies • Cheek swab • Not saliva, but “oral mucosal transudate”, a fluid produced by cheek cells • “Visual” • In 1985, WHO developed the “Bangui Definition” for use in countries without antibody testing technology • Sometimes more informal… “Slim disease”

14. Bangui Definition • Exclusion criteria • Pronounced malnutrition • Cancer • Immunosuppressive treatment • Inclusion criteria with the corresponding score • Weight loss exceeding 10% of body weight 4 • Protracted asthenia 4 • Continuous or repeated attacks of fever for more than a month 3 • Diarrhoea lasting for more than a month 3 • Cough 2 • Pneumopathy 2 • Oropharyngeal candidiasis 4 • Chronic or relapsing cutaneous herpes 4 • Generalized pruritic dermatosis 4 • Herpes zoster (relapsing) 4 • Generalized adenopathy 2 • Neurological signs 2 • Generalized Kaposi's sarcoma 12 • The diagnosis of AIDS is established when the score is 12 or more.

15. CD4 Count • A proxy measurement of the strength of a patient’s immune system • CD4 count goes down as HIV infection progresses • Used in coordination with… Viral Load Test • The amount of HIV virus in the blood, lymph, spleen, and other body parts • Viral load goes up as HIV infection progresses

16. HIV/AIDS in the Developed World Case study: USA

20. HIV/AIDS Around the World To get current data, go to: http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp

21. UNAIDS 2008

22. *detection bias? New AIDS Cases Per Year Per 100,000 Population 35 Caribbean 30 25 20 North America 15 10 Latin America 5 0 2000 90 91 92 93 94 95 96

23. Estimated number of adult and child deaths due to AIDS globally, 1990–2007 3.0 Millions 2.5 2.0 1.5 1.0 0.5 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year This bar indicates the range around the estimate 5.3

25. The red bits are what we call “Sub-Saharan Africa”

26. Estimated number of people living with HIV and adult HIV prevalence Global HIV epidemic, 1990‒2005* HIV epidemic in sub-Saharan Africa, 1985‒2005* Number of people living with HIV (millions) % HIV prevalence, adult (15‒49) Number of people living with HIV (millions) % HIV prevalence, adult (15‒49) 50 5.0 30 15.0 12.5 25 40 4.0 20 10.0 30 3.0 7.5 15 20 2.0 5.0 10 10 1.0 2.5 5 0 0.0 0 0.0 1990 1995 2000 2005 1985 1990 1995 2000 2005 *Even though the HIV prevalence rates have stabilized in sub-Saharan Africa, the actual number of people infected continues to grow because of population growth. Applying the same prevalence rate to a growing population will result in increasing numbers of people living with HIV. Number of people living with HIV % HIV prevalence, adult (15-49) This bar indicates the range around the estimate 2.2

27. Regional HIV and AIDS statistics and features, 2006 Adults & children living with HIV Adults & children newly infected with HIV Adult (15‒49) prevalence [%] Adult & child deaths due to AIDS Sub-Saharan Africa 24.7 million [21.8 – 27.7 million] 2.8 million [2.4 – 3.2 million] 5.9% [5.2% – 6.7%] 2.1 million [1.8 – 2.4 million] Middle East & North Africa 460 000 [270 000 – 760 000] 68 000 [41 000 – 220 000] 0.2% [0.1% – 0.3%] 36 000 [20 000 – 60 000] South and South-East Asia 7.8 million [5.2 – 12.0 million] 860 000 [550 000 – 2.3 million] 0.6% [0.4% – 1.0%] 590 000 [390 000 – 850 000] East Asia 750 000 [460 000 – 1.2 million] 100 000 [56 000 – 300 000] 0.1% [<0.2%] 43 000 [26 000 – 64 000] Latin America 1.7 million [1.3 – 2.5 million] 140 000 [100 000 – 410 000] 0.5% [0.4% – 1.2%] 65 000 [51 000 – 84 000] Caribbean 250 000 [190 000 – 320 000] 27 000 [20 000 – 41 000] 1.2% [0.9% – 1.7%] 19 000 [14 000 – 25 000] Eastern Europe & Central Asia 1.7 million [1.2 – 2.6 million] 270 000 [170 000 – 820 000] 0.9% [0.6% – 1.4%] 84 000 [58 000 – 120 000] Western & Central Europe 740 000 [580 000 – 970 000] 22 000 [18 000 – 33 000] 0.3% [0.2% – 0.4%] 12 000 [ <15 000] North America 1.4 million [880 000 – 2.2 million] 43 000 [34 000 – 65 000] 0.8% [0.6% – 1.1%] 18 000 [11 000 – 26 000] Oceania 81 000 [50 000 – 170 000] 7100 [ 3400 – 54 000] 0.4% [0.2% – 0.9%] 4000 [2300 – 6600] TOTAL 39.5 million [34.1 – 47.1 million] 4.3 million[3.6 – 6.6 million] 1.0% [0.9% - 1.2%] 2.9 million [2.5 – 3.5 million] Table 1b

28. Percentage of the Adult (ages 15-49) population with HIV/AIDS, 2003

30. 70 Sub-Saharan Africa 60 GLOBAL 50 Percent female (%) Caribbean 40 Asia 30 Latin America 20 Eastern Europe & Central Asia 10 0 1990 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 2000 ‘01 ‘02 ‘03 ‘04 ‘05 ‘06 2007 Percent of adults (15+) living with HIV who are female 1990–2007 2.4

31. Haiti – HIV Seroprevalence: gender split

32. Proportions of HIV infections in different population groups by region, 2005 Eastern Europe and Central Asia Latin America South and South-East Asia* MSM 26% CSW clients 41% CSW 4% MSM 4% CSW 5% CSW clients 13% CSW clients 7% CSW 8% IDU 67% IDU 19% MSM 5% All others 38% All others 17% All others 24% IDU 22% IDU: Injecting Drug Users MSM: Men having sex with men CSW: Commercial Sex Workers * India was omitted from this analysis because the scale of its HIV epidemic (which is largely heterosexual) masks the extent to which other at-risk populations feature in the region’s epidemics. Figure 2

33. Why “MSM”? • Sexuality is culturally defined • Men having sex with men do not necessarily self-identify as homosexual • Sociologically: • MSM refers to the sexual relationship between two men • Homosexuality refers to broader relationships between men, beyond the sexual

34. Truck Drivers • Yes, truck drivers • The spread of HIV in Africa is linked to the movement of labour between rural and urban centres • Geographical link between HIV clusters and road networks • Truck drivers have high-risk behaviour of sleeping with prostitutes and a tendency to spread the infection along trade routes

35. Impact of AIDS on Sub-Saharan Africa • 2/3 of all people with HIV live in this region • 75% of all AIDS deaths occur here • (region comprises only 10% of world population) • Each year, >2 million people died of AIDS in this region • In this region, direct medical treatment related to AIDS (not including ARV) = US$30 per person per year • Overall public health spending is <US$10 per person per year* * UNAIDS 2002 Report on the Global AIDS Epidemic

36. Impact… • Hospitals • People with HIV occupy half of all hospital beds • Shortage means only people in later stages are admitted, resulting in lessened treatment success • Health Care Workers • Large numbers are HIV or AIDS positive • Dwindling numbers • Providing ARVs requires more training *UNAIDS, 2006 Report on the Global AIDS Epidemic, chapter 4: The impact of AIDS on people and societies

37. Household Impact • Wage earners killed off -> impoverished families • Young forced into prostitution -> increased disease transmission • AIDS has erased much of the anti-poverty progress made over the past 6 decades • Basic necessities not being provided • There are entire communities with no adults left -> households led by small childen • No transfer of knowledge from adults to children

38. Food Production • Not enough labour to work fields • In Malawi, Botswana, Zimbabe, agricultural output will drop 14%-20% by 2020 due to AIDS • The use of ARV requires proper nutrition • Vicious cycle: • AIDS -> poor food production -> poor nutrition -> more AIDS

39. Anti Retrovirals

40. Number of people receiving antiretroviral drugs in low- and middle-income countries, 2002−2007 3.0 2.8 North Africa and the Middle East Millions 2.6 2.4 2.2 Eastern Europe and Central Asia 2.0 1.8 1.6 East, South and South-East Asia 1.4 1.2 Latin America and the Caribbean 1.0 0.8 0.6 Sub-Saharan Africa 0.4 0.2 0.0 end- 2002 end- 2003 end- 2004 end- 2005 end- 2006 end- 2007 Year Source: Data provided by UNAIDS & WHO, 2008. 5.2

41. Gender Disparity • The impact of AIDS in Africa is felt disproportionately by women • In many circles, AIDS is no longer a “gay disease”, but a “woman’s disease”, since >50% of all cases are borne by heterosexual women • Women function as family care givers, and are now the sole providers • Leading to neglect in care-giving

42. AIDS “Virgin Myth” • It is believed that an HIV-infected man will be cured if he has unprotected sex with a virginal female • -> epidemic of child rape • -> emerging epidemic of rape of the disabled • Global movement to re-educate those at risk • South African group “Love Life” • www.lovelife.org.za

43. Circumcision • Some studies suggest that male circumcision can reduce HIV transmission (via sex) by >50% • Presently, there are vocal advocates to make circumcision mandatory in high risk communities • Global teams offering free, safe circumcisions in Swaziland, Botswana and elsewhere

44. Nice Summary • Of some of the AIDS impacts is found here: • http://www.avert.org/aidsimpact.htm

45. Orphans: A Lost Generation • Numbers are large and growing • Social support systems are overwhelmed • Risk of a lost generation: • little or no education • poor socialization • social upheaval • economic underclass

46. Debt -Kenya pays 17X more on debt repayment than on HIV control

47. Economic Growth Impact of HIV (1990-97) (Data from 80 developing countries) 0 -0.2 -0.4 -0.6 -0.8 Reduction in growth rate GDP per capita (%, per year) -1 -1.2 -1.4 -1.6 0 5 10 15 20 25 30 35 HIV Prevalence Rate (%) Source: R. Bonnel (2000) Economic Analysis ofHIV/AIDS, ADF2000 Background paper, World Bank

48. “There are two refrains which I’ve regularly (and painfully) heard over the last three years traveling in Africa, always coming from young [African] women with their children in tow: ‘What will happen to my children when I die?’ and ‘You have drugs to treat people in your country; why can’t I have drugs to stay alive in my country?’ -Stephen Lewis

49. Even if we made ARVs dirt cheap, would this solve the problem? • Bill Clinton: "90% of HIV positive people in the developing world are unaware of their [disease] status.“ • Bill Gates: "The capacity to treat [AIDS] is not so much gated by access to drugs as it is by the availability of trained personnel."